Dai et al from China review the evidence in regard to the treatment of thoracolumbar burst fractures. This review is well done but leaves the reader wondering what is the right approach to take in the management of thoracolumbar burst fractures. It does appear that, in patients without a neural deficit, nonoperative therapy is appropriate. Yet, there are many studies they cite, mostly all using different approaches—anterior, posterior, or anterior-posterior combined to treat patients with fractures and neurologic deficits. I am amazed at all the suggested treatments, a clear sign that no single approach has become dominant. Also, there is a lack of randomized studies—a subject I have discussed many times. Where are the national spine societies in helping solve this controversy? This is a very good review and is an example of the need for leadership in this field.
In a second paper, Dai et al from China evaluate the neurologic recovery after thoracolumbar burst fractures. They question whether the canal encroachment and kyphosis have any relationship to recovery. They found that these factors do not have any influence on the recovery achieved. One of the major reasons given for operative approaches to burst fractures is to allow more neurologic recovery. However, according to these authors that thinking is incorrect. It appears that the neurologic injury is related to the energy transmitted to the cord at the initial impact. If this hypothesis is correct, surgery is done for stabilization. According to the authors' previous paper, there is a controversy not only on whether decompression and fusion are necessary for this stabilization but also which procedure among the many is effective. This paper reminds me of the controversy in regard to the treatment of an unstable cervical spine injury with a neurologic deficit. The reason for surgery is to stabilize the osseous elements, not to promote neurologic recovery.
Ding et al from China have done a superb piece of work to determine the cell of origin of hemangioblastomas and the proliferating component cell. This is an easy paper to read; yet, it gives us an insight into more advanced methods of distinguishing the basic cellular characteristics of tumor cells. The authors found no biochemical differences in the molecular markers of growth tested between the cystic and solid hemangioblastomas. Also, it appears from their research that the hemangioblastomas are not ectodermal or reticuloendothelial in origin, which is a subject of controversy. Yet the stromal cells have vascular endothelial growth factor receptors, which are stimulated to produce growth of these cells in hemangioblastomas. Other studies assessing telomerase activity, a marker of cell proliferation, pointed to the stromal cells as the essential growing element of the tumor. Endothelial cells and pericytes, which are the other 2 components of the tumor, do not have the proliferative potential of the stromal cells. So, the stromal cells are the growth focus of this tumor. This is the kind of study that begins to provide an understanding of the factors in neoplastic proliferation and can lead to cellular and molecular therapies in the future.
Finn et al from the USA describe 3 cases with postictal magnetic resonance fluid-attenuated inversion recovery imaging changes in patients with brain tumors. These changes resolved on repeat imaging and were not indicative of tumor progression. So, imaging changes after a seizure in a tumor patient may not be indicative of tumor progression. Read Sotelo's note at the end for a wider perspective on this paper.
Das et al from India present their series of 10 cases of Cushing's disease in a pediatric population and discuss its management. Laws and van Guilder agree with and compliment their approach.
Flores et al from Brazil report a nice series of 8 patients with lipomas producing compression of peripheral nerves. The patients presented with entrapment neuropathies. They discuss their preoperative diagnosis and surgical management of these lesions. Read Zager's comments at the end.
Setzer et al from Germany study the effects of atmospheric pressure changes on subarachnoid hemorrhage. Read Dickey's comments at the end. We may all have suspected such an effect, but is this proof? As Dickey states, the hypothesis does not explain all the observations. Read the abstract and Dickey's comments. Then you can read more if the subject interests you.
Fujimura et al from Japan have done an excellent study to understand why patients who undergo a superficial temporal artery–middle cerebral artery bypass experience a neurologic deterioration. This study is well done and shows that the neurologic deterioration is related to the hyperperfusion produced after the bypass. Treatment is by blood pressure reduction and control, a practice that is the opposite of what we might think.
Yoshiyama et al from Japan have a unique referral practice of patients with decompression sickness after deep diving and in particular spinal cord damage resulting from this problem. They found lesions on T2-weighted magnetic resonance images within 24 hours of the acute neurologic presentation. The pathology from animal studies suggests that “infarction, edema, axonal degeneration, and demyelination” occur as a result of the decompression. The discussion details several etiologies that are considered for the pathogenesis. Although the patients were treated with hyperbaric oxygenation and steroids, their improvement was limited and in fact their course was one of neurologic deterioration from admission.
Yoshida reports his unique experience with brain metastases from esophageal cancer. He had a series of more than 800 patients with brain metastases and more than 1100 patients with primary esophageal cancer, a common tumor in Japan.
Miyazawa et al from Japan have a very practical solution to a common problem of bone flap and scalp infection after craniotomy with reduction in the scalp available to close the incision. After failing to eradicate the infection with antibiotics, the authors removed the bone flap and expanded the adjacent scalp tissue with a tissue expander. They then performed a cranioplasty and closed the newly expanded scalp. This technique has been around for some time and was used in wartime injuries to allow wound closure.
Cone et al have another nice academic report on a new infectious variant of Streptococcus to produce a brain abscess.
de Souza et al from Brazil report on the angioplasty and stenting of the proximal segment of an occluded subclavian artery in a patient with bilateral internal carotid occlusions and a subclavian right to left steal. This is an excellent use of interventional approaches to treat vascular pathology, in this case the subclavian steal syndrome.
This month Miguel Faria has written the second of his 2-part editorial on his experience as a reviewer of public health studies submitted for grants. He finds that the studies proposed are more instruments for social change and not well-founded scientific proposals.
My editorial this month is about the growth of neurosurgery in the developing world using China as an example. It also examines the bias of the developed world toward the science and scientists of the developing world. “Scientific Colonialism” as I name it.
Again thanks for taking the time to read Surgical Neurology. We hope that you have learned something, as we have, from these papers.
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